Healthcare Provider Details

I. General information

NPI: 1740194695
Provider Name (Legal Business Name): MOUNTAIN COMPREHENSIVE CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 HALLWOOD DR
MOREHEAD KY
40351
US

IV. Provider business mailing address

104 S FRONT AVE
PRESTONSBURG KY
41653-1614
US

V. Phone/Fax

Practice location:
  • Phone: 606-886-8572
  • Fax:
Mailing address:
  • Phone: 606-886-8572
  • Fax: 606-886-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROXANN CORDIAL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 606-886-8572